HRA Claim Form

You can also submit claims and upload receipts online by visiting www.cdphp.com
and logging into the CDPHP member site. NOTE: You can also use this form to have
out-of-pocket pharmacy expenses added to your HRA deductible.
Employer: Subscriber Name:

Member Name: Member ID # :

Address:

City: State: ZIP:

Phone: Email:

USE A SEPARATE HRA EXPENSE CLAIM FORM FOR EACH FAMILY MEMBER
Does your receipt include Provider’s name Provider’s address Description of service or product Requested amount
all of the following? Actual date(s) of service (Date of payment is not sufficient)
Requested
Date of Service Provider’s Name Description of Service or Product Amount

Attach appropriate receipt(s) and submit with this

Total HRA Expense $
claim form to ensure proper processing.

Read Carefully: The undersigned participant in the Health Reimbursement Arrangement Plan (Plan) hereby certifies that all services for which
reimbursement or payment is claimed by submission of this form were provided during a period while the undersigned was covered under his or her
employer’s HRA. In addition, the undersigned participant certifies that the medical expenses have not and will be not reimbursed under any other health
plan coverage. The undersigned understands that he or she alone is fully responsible for the sufficiency, accuracy, and validity of all information relating
to this claim, which is provided by the undersigned, and that unless an expense for which payment or reimbursement is claimed is a proper and eligible
expense under the HRA, the undersigned may be liable for payment of all related taxes including federal, state, or city income tax on amounts paid from
the Plan which relate to such expense.
There may be certain limitations on the types of health care expenses that are eligible for reimbursement under the HRA. If you have specific questions
regarding the types of expenses that are covered under your HRA, please contact your employer’s benefit department.

Subscriber’s Signature Date

Submit claims and upload receipts online by logging into www.cdphp.com, or mail or fax claim form and receipts to:
CDPHN • P.O. Box 6130 • Albany, NY 12206-0130 • Fax: (518) 641-3502
Funding account questions? Call (518) 641-3770 or toll free 1-877-793-3960
Access your account information 24/7 at www.cdphp.com
Capital District Physicians’ Healthcare Network, Inc.  19-11507
HRA Claim Form and Filing Instructions
Your claim is important to us. To ensure CDPHP is able to process your ®

reimbursement or apply out-of-pocket pharmacy expenses to your HRA

deductible, fully complete an HRA claim form. Please review the guidelines listed
below to ensure all necessary information is included when filing your claim.
ffThis plan is governed by IRS guidelines. In order
to satisfy IRS requirements, documentation is
needed to process your claim. Include a receipt or
explanation of benefits (EOB) for every expense.
The receipt or documentation must contain:
Date of service – Date service(s) occurred or
date item was purchased.
Provider’s name and address – Who delivered
the service, or if a purchase, where item was
purchased.
Description of service – Description of the
service or product that was paid for.
Requested amount – The amount paid for
the services or product and/or portion not
reimbursed through your other insurance carrier.
ffUse a separate form for each family member.
Additional forms can be downloaded from
www.cdphp.com.
ffTo be considered for reimbursement, over-the-
counter medications will require a doctor’s
prescription. Please make sure you attach a
copy each time.
ffCircle the dollar amount being claimed on each
receipt. Do not use a highlighter.
ffIf you are covered by other insurance for the
services provided, you should submit those
charges to the insurance company first and then
send the EOBs to us along with this claim form.
ffIf you have dental insurance, please send a copy
of your EOB with your proof of payment.
ffIf you have medical coverage for eyeglasses and
contacts, you should only pay with your HRA for
the amount above your medical allowance. Your
vision provider should submit a claim for medical
coverage directly to the insurance company.
ffCancelled checks, credit card slips, or statements
showing only balance due on your account are
not allowable.
ffClaims must be received by CDPHN within the
timeframes specified in your Plan. Claims must
be submitted after a service is provided, but
before the end of the run-out period following the
end of your Plan year.
ffThe expenses being claimed cannot be
reimbursed from any other source.
ffKeep a copy of the claim form and supporting
documents for your records.
ffIn the event you are asked to resubmit a claim
due to insufficient information, you must submit
a new claim form with the requested information.
Fax your claim form with receipts to CDPHN at
(518) 641-3502, or mail them to CDPHN,
P.O. Box 6130, Albany, NY 12206-0130.
You can also submit claims and upload receipts online,
or check your account balance status any time, day or
night, by logging in to the secure member site on our
website at www.cdphp.com.

Discrimination is Against the Law

Capital District Physicians’ Health Plan, Inc. (CDPHP ) complies with applicable federal civil rights laws and does not
®

discriminate on the basis of race, color, national origin, age, disability, or sex.

Multi-language Interpreter Services

ATENCIÓN: Si habla otro idioma que no es el inglés, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al número que figura en su tarjeta de identificación de miembro (TTY: 711).
注意：如果您使用的語言不是英語，您可以免費獲得語言援助服務。請致電您會員ID卡上的電話（聽力障礙電傳：711）。

Capital District Physicians’ Healthcare Network, Inc.  19-11507